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Antiretroviral Therapy in Latin America: North of the Southern Cone, a Good Plan Is Hard to Find

When Agua Buena's Richard Stern writes, below, about a recent trip to the AIDS hospitals and advocacy groups of Lima, Perú, he could just as easily been describing the situation in Santo Domingo, Tegucigalpa, Guatemala City, or any number of Latin American capital cities. Easily, of course, is a poorly chosen word. He watches as a Catholic priest performs the last rites to three Gen X women -- women with HIV who died of a simple OI which a couple doses of fluconazole would have cleared up. Women for whom the price of an antifungal medicine we might now take for granted made the difference between dying young and surviving to fight another day.

It is the gentle simplicity of Richard's travelogues that render their bite all the more arresting. Working from the smallish San José apartment that doubles as his office, he might be the Sister Mary Elizabeth of Central America: quietly transforming the region's response to HIV one village at a time. A man on a mission determined to arm the masses with those most powerful of weapons: knowledge, solidarity and hope. "Sometimes I have the impression that the situation in Latin America is simply too insignificant to receive the prioritization it deserves," he observes in what would appear to be a rare disconsolate moment. He has been an enormous help in preparing this special TAGline dedicated to the plight of people with HIV in Latin America and the Caribbean. His take on Panamá and Honduras appears in "ACTing UP for Treatment Access in Latin America" in this issue. More of his work and writing can be found at the foundation's Web site, www.aguabuena.org.

The situation regarding AIDS in Latin America reflects the public health situation in general. Only a few miles from this beautiful neighborhood called Miraflores is a public hospital for women called Loaiza. I visited that hospital last September accompanied by Father Jose Fedora, a priest here in Lima who provides support to people living with HIV/AIDS. Father Fedora went to the hospital, as he does several times a week, to counsel patients with AIDS who are there.

The day I accompanied him he was also administering the last rites of the Roman Catholic church to three women (none of them over 35) who were dying of severe opportunistic infections. There were no medications provided in the hospital for these infections, so the women were dying from an infection that could have been cured with a ten-day supply of fluconazole. But the medication was too expensive for these women.

In the public hospitals in Perú, there is no guarantee that you will receive treatment -- even for medications that cost as little as $1 or less per day -- unless your family can buy your medications for you. To see the rows and rows of beds filled with sick women who apparently receive only minimal medical attention was a sobering experience, especially when I considered the contrast to the obvious affluence of the neighborhood I had just come from. Of course, I have also visited public hospitals such as these in Guatemala, Honduras, Belize, and El Salvador.

This is typical of the panorama around the region. There is a divided health care system here in Perú -- as well as in Ecuador, El Salvador, Guatemala, and Panamá -- where those who have access to the "Seguro Social" will, most often, receive relatively good medical care, including antiretrovirals. Those who are not included in this system receive abysmal care. [NB: The Latin American version of Social Security is different from that of the United States and is more of a middle and upper-middle class entitlement.]

Of course the non-included individuals are the nation's poor -- the informal labor force who cannot affiliate with the Seguro Sociales. So the whole societal value system with respect to not just AIDS, but other diseases as well, is that the poor are expendable. The role of Latin America governments (with some exceptions such as Brazil) seems to be to protect the wealth of the rich, because of a fear that there would not be enough money available if the poor were to be treated decently by the government.

AIDS then, as a disease that requires economic resources from the state, is a threat to these governments. It is also a fundamental reason why people with AIDS do not receive adequate care and attention. AIDS activists focus a lot on discrimination -- specifically against people living with HIV/AIDS. And, a priori, discrimination is a critical factor related to the poor medical attention that people with AIDS receive. But the fact of being poor automatically makes a person vulnerable to discrimination in these societies -- whether they have AIDS or not.

Sometimes I have the impression that the situation in Latin America is simply too insignificant to receive the worldwide prioritization it deserves. The figures presented in the accompanying table are dwarfed by the constant media reports about the millions of people in Sub-Saharan Africa who are dying of AIDS. In this updated table, you can see that in our target countries we estimate that there are 95,000 people who need medications.

These are 95,000 lives, and each one is worth saving. But the pressure on these government to provide treatment, I think, has ironically been lessened by all the attention focused on Africa -- and Brazil. If there is a country in Latin America that receives a majority of the world's attention in the media, it is Brazil: again, ironically and deservedly, for its progressive politics of local generic production and universal medicines access for 110,000 people. But you rarely, if ever, see anything in the media about the situation of those living with HIV/AIDS in, for example, Bolivia or Ecuador or Guatemala.